Encourage Patients to Call Between Visits for Better Toxicity Management During Treatment

Rowena N. Schwartz, PharmD, BCOP, FHOPA, Professor of Pharmacy Practice, University of Cincinnati School of Pharmacy, Ohio, joined Pharmacy Times at HOPA Annual Conference 2023 to discuss why patients may fear a conversation with the pharmacist, the significance of the oncology patient having an active role in their toxicity management strategy, and continued education.

PT Staff: How strongly should a pharmacist consider guidelines when selecting a therapy for a patient with mRCC (metastatic renal cell carcinoma)?

Rowena N. Schwartz, PharmD, BCOP, FHOPA, Well I think there's 2 things. One is that you have to very much look at individual factors for a patient. And that can be health-related things that can be socioeconomic, and those things are very important to consider. In that context, then look at the guidelines for recommendations based on the literature. I think having good guidelines are essential and help has helped move practice forward. But it's always important to realize that guidelines are just that: guidelines. And that you really need to look at patient factors, and patient considerations, what they want, when you're making a determination of what their best treatment strategy should be.

PT Staff: What are the most common toxicities associated with approved mRCC treatment options, and how do you approach creating a toxicity management strategy?

Rowena N. Schwartz, PharmD, BCOP, FHOPA, I'm going to go with the same theory in terms of management strategy. And that is looking at the patient and individualizing the care that you provide. So, there are 2 major groups of drugs that we use— very different toxicity, some overlapping. So, the immune checkpoint inhibitors (ICIs), we have a lot of experience with them now. But they can be very toxic drugs in certain patients and very tolerable, and others, the vascular endothelial growth factor (VEGF) tyrosine kinase inhibitors (TKIs), they have a different group of toxicities. And each of the agents we have a number that we can choose from, they have a little bit different toxicity. So, when I look at a treatment strategy, I look at patient's comorbidities, I look at other medications that they're on, and try to figure out a way to not only educate them but to monitor them throughout therapy— to ensure that when anything changes, we can intervene immediately. And so, I think the best strategy is to engage the patient and or the caregiver in being part of that assessment strategy, so that you can help them if a toxicity does occur. And I think that's 1 of the biggest challenges in practice; helping patients know that it's okay to call between visits, that it's really important to call between visits, if there's something new, and that your part of their team. And it may not be you that they call it may be another team member, but it's really important to help them assess what's going on and determine if you should do some changes in treatments of maybe they're comorbidities or maybe some changes in treatments with the anti-cancer therapy. So that kind of kind of shared oversight is important and care for these patients.

PT Staff: Why might a patient fear reaching out to their pharmacist or healthcare provider between visits to discuss their condition/medication?

Rowena N. Schwartz, PharmD, BCOP, FHOPA, I think there's a lot of reasons, I think that question is important. For every individual, there's probably a different reason why they're afraid. Some people are afraid you're going to tell them to hold their medication, and holding their medication in their mind may mean my diseases not getting treated. Some people are afraid that you're going to add an additional medication and adding an additional medication may be extra cost. Some people just think things are going to be okay. So it really depends on the individual. So kind of getting to know that person (and I don't mean just me getting to know that person but the team knowing) so that you can better understand what is important for that patient, their family, and caregiver helps you better address those kinds of questions about why they're afraid to talk to you.

PT Staff: How can oncology pharmacists properly educate patients to improve medication therapy management?

Rowena N. Schwartz, PharmD, BCOP, FHOPA, I kind of look at this as 2 things; one is educating the patient and the family caregiver, and [determining] who the person who wants that information is, you have to find out. But I think it's important to realize that educating at the beginning of therapy does not continue in their head on to month 6. So, it's really important to do that reeducation. So, if someone doesn't have a toxicity, they pretty much think they're not going to after a couple of weeks, but these toxicities can come at any time. So, it's really important to do reeducation and re-emphasize things throughout the course of care.

The other thing is that I think it's important to engage other health care team members in their management. And what I mean here is their primary care physicians, letting them know what treatments that they're on, because some of their comorbidities may be impacted somebody with hypertension, they may have increased blood pressure. And that management strategy needs to be coordinated. And so, I think that's also telling [to] have the patient’s family talk to their community pharmacist so they know what medications they're on, even if they're getting them from a different source. So again, that they can look at the drug-drug interactions. I really think education is educating the patient family and caregivers throughout care, but also educating their whole health care team, primary care specialists, other pharmacists so that the whole team is working together to manage the patient.